Unique identification number given to the study site to distinguish the location where data is recorded.

Site

Alphanumeric

The site identifiers or IDs should be assigned by the study.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

SITE

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

Site identifier

255

Free-Form Entry

C19247

Subject ID

SubIDNam

Subject identification ID

Subject

Alphanumeric

The participant or subject identifiers or IDs should be assigned by the study.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

1.0

6/5/2014

Aliases for variable name not defined

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

255

Free-Form Entry

C06005

Data collected date and time

DataCollDateTime

Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed.

Date Time of Exam

Date or Date & Time

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015.

Adult;Pediatric

Core

3.0

7/24/2013

Aliases for variable name not defined

International Standards for Neurological Classification of SCI Worksheet

This element and the 'SCI Classification motor or sensory exam laterality type' element should be used with the subsequent motor grades and scores to identify with which anatomic site and side (i.e., left or right) the motor grade/score is associated.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

Refer to SCI CDE Annotated Form

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification motor exam anatomic site

Single Pre-Defined Value Selected

C02411

Laterality type

LatTyp

Laterality type relative to the anatomic site of the body examined or affected

R L

Alphanumeric

This element, and the 'SCI Classification motor exam anatomic site' and 'SCI Classification sensory exam anatomic site' elements as applicable, should be used with the subsequent motor and sensory grades and scores to identify with which anatomic site and side (i.e., left or right) each motor and sensory grade/score is associated.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

8/28/2013

Aliases for variable name not defined

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

Laterality type

Single Pre-Defined Value Selected

C06337

SCI Classification motor exam anatomic site grade

SCIClssMtrExamAntmicSiteGrd

Grade that documents the movement, range of motion, and resistance of the specific muscle on the right or left side.

Muscle Grading

0;1;2;3;4;5;5*;NT;

Total paralysis;Palpable or visible contraction;Active movement, full range of motion, gravity eliminated;Active movement, full range of motion, against gravity;Active movement, full range of motion, against gravity and provides some resistance;Active movement, full range of motion, against gravity and provides normal resistance;Muscle able to exert, in examiner’s judgment, sufficient resistance to be considered normal if identifiable inhibiting factors were not present;Not testable;

Alphanumeric

Choose best score and record for each muscle on each sideCore for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

Refer to SCI CDE Annotated Form

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification motor exam anatomic site grade

Single Pre-Defined Value Selected

C06419

SCI Classification motor strength upper limb single side score

SCIClssMtrStrgthUpLmbSnglSdScr

Score of motor strength for the upper limb on the specific side

Motor Upper Limb R/L

Numeric Values

Should be calculated/derived from the raw data. The maximum score for each side is 25.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

MTRULL; MTRULR

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification motor strength upper limb single side score

Free-Form Entry

C06320

SCI Classification motor strength upper limb total score

SCIClssMtrStrgthUpLmbTtlScore

Total score of motor strength for the upper right and left limbs.

Motor Upper Limb Total

Numeric Values

Should be calculated/derived from the raw data. The maximum total score is 50.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015.

Adult;Pediatric

Core

3.0

7/17/2013

MTRULT

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification motor strength upper limb total score

Free-Form Entry

C06420

SCI Classification motor strength lower limb single side score

SCIClssMtrStrgthLwLmbSnglSdScr

Score of motor strength for the lower limb on the specific side.

Motor Lower Limb R/L

Numeric Values

Should be calculated/derived from the raw data. The maximum score for each side is 25.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015.

Adult;Pediatric

Core

3.0

7/17/2013

MTRLLL; MTRLLR

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification motor strength lower limb single side score

Free-Form Entry

C06347

SCI Classification motor strength lower limb total score

SCIClssMtrStrgthLwLmbTtlScore

Total score of motor strength for the lower right and left limbs.

Motor Lower Limb Total

Numeric Values

Should be calculated/derived from the raw data. The maximum total score is 50.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

MTRLLT

International Standards for Neurological Classification of SCI Worksheet

This element and the 'SCI Classification Sensory Exam Laterality Type' element should be used with the subsequent sensory grades and scores to identify with which anatomic site and side (i.e., left or right) the sensory grade/score is associated.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

Refer to SCI CDE Annotated Form

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification sensory exam anatomic site

Single Pre-Defined Value Selected

C06325

SCI Classification light touch anatomic site grade

SCIClssLteTchAntmicSteGrd

Grade that documents the ability to sense light touch on the specific spinal cord level and side

Ability, Impaired, Normal, Not Testable

0;1;2;NT;

Absent;Impaired;Normal;Not testable;

Alphanumeric

Choose the best score and record for each spinal cord level and side.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

Refer to SCI CDE Annotated Form

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification light touch anatomic site grade

Single Pre-Defined Value Selected

C06421

SCI Classification light touch single side score

SCIClssLghtTchSnglSdScore

Score of sensation of light touch for the specific side of the body.

Light Touch R/L

Numeric Values

Should be calculated/derived from the raw data. The maximum score for each side is 56.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

SENSLTL; SENSLTR

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification light touch single side score

Free-Form Entry

C06329

SCI Classification light touch total score

SCIClssLteTchTtlScore

Total score of sensation of light touch on the right and left sides of the body.

Light Touch Score

Numeric Values

Should be calculated/derived from the raw data. The maximum total score is 112.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

SENSLTT

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification light touch total score

Free-Form Entry

C06331

SCI Classification pin prick anatomic site grade

SCIClssPnPrckAntmicSiteGrd

Grade of the ability to sense a pin prick on the specific spinal cord level and side

Ability, Impaired, Normal, Not Testable

0;1;2;NT;

Absent;Impaired;Normal;Not testable;

Alphanumeric

Choose the best score and record for each spinal cord level and side.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

Refer to SCI CDE Annotated Form

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification pin prick anatomic site grade

Single Pre-Defined Value Selected

C06422

SCI Classification pin prick single side score

SCIClssPnPrckSnglSdeScore

Score of sensation of a pin prick for the specific side of the body.

Pin Prick R/L

Numeric Values

Should be calculated/derived from the raw data. The maximum score for each side is 56.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

SENSPPL; SENSPPR

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification pin prick single side score

Free-Form Entry

C06335

SCI Classification pin prick total score

SCIClssPnPrckTtlScore

Total score of a pin prick on the right and left sides of the body.

Pin Prick Score

Numeric Values

Should be calculated/derived from the raw data. The maximum total score is 112.Core for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

SENSPPT

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification pin prick total score

Free-Form Entry

C06387

SCI Classification anal contraction voluntary indicator

SCIClssAnalContVolunInd

Indicator of whether or not the patient can have a voluntary anal contraction.

Voluntary anal contraction

Yes;No;Unknown;

Yes;No;Unknown;

Alphanumeric

Choose oneCore for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

ANALCONT

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification anal contraction voluntary indicator

Single Pre-Defined Value Selected

C06348

SCI Classification anal sensation indicator

SCIClssAnalSensInd

Indicator of whether or not the person has any anal sensation.

Any anal sensation

Yes;No;Unknown;

Yes;No;Unknown;

Alphanumeric

Choose oneCore for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

ANALSENS

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification anal sensation indicator

Single Pre-Defined Value Selected

C06006

SCI Classification sensory neurological level left result

SCIClssSensNeuroLvlLftReslt

Result of the most caudal segment of the spinal cord on the left side of the body with normal sensory function for pinprick and light touch.

If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.Core for ages 6 and older.

DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points.

Adult;Pediatric

Core

3.0

7/17/2013

SENSLVLL

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification sensory neurological level left result

Single Pre-Defined Value Selected

C06007

SCI Classification sensory neurological level right result

SCIClssSensNeuroLvlRtReslt

Result of the most caudal segment of the spinal cord on the right side of the body with normal sensory function for pinprick and light touch.

If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.Core for ages 6 and older.

DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points.

Adult;Pediatric

Core

3.0

7/17/2013

SENSLVLR

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification sensory neurological level right result

Single Pre-Defined Value Selected

C06008

SCI Classification motor neurological level left result

SCIClssMtrNeuroLvlLftReslt

Result of the lowest key muscle on the left side of the body that has a grade of at least 3, provided the key muscles represented by segments above that level are judged to be normal (grade 5).

If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.Core for ages 6 and older.

DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points.

Adult;Pediatric

Core

3.0

7/17/2013

MTRLVLL

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification motor neurological level left result

Single Pre-Defined Value Selected

C06009

SCI Classification motor neurological level right result

SCIClssMtrNeuroLvlRteReslt

Result of the lowest key muscle on the right side of the body that has a grade of at least 3, provided the key muscles represented by segments above that level are judged to be normal (grade 5).

If only the alphabetic part of the level is known, it is permissible to use code C, L, T, or S followed by numeric code "99". Use code X99 if the level is completely unknown, the exam was not done, or there was no corresponding admission or discharge.Core for ages 6 and older.

DeVivo M, Biering-Sørensen F, Charlifue S, Noonan V, Post M, Stripling T, Wing P. International Spinal Cord Injury Core Data Set. Spinal Cord 2006 Sep;44(9):535-40. Refer to the latest published version of The International Standards for Neurological Classification of Spinal Cord Injury for complete information on the sensory examination and a listing of all key points.

Adult;Pediatric

Core

3.0

7/17/2013

MTRLVLR

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification motor neurological level right result

Single Pre-Defined Value Selected

C06410

SCI Classification S4-S5 sensory function result

SCIClssS4S5SensFuncReslt

Result of the extent to which motor or sensory function is preserved in the sacral segments S4-S5.

Complete or Incomplete?

Complete;Incomplete;

No motor or sensory function is preserved in the sacral segments S4-S5;Some motor or sensory function is preserved in the sacral segments S4-S5.;

Alphanumeric

Choose oneCore for ages 6 and older.

Used with permission of the American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2011; Atlanta, GA. Updated 2015

Adult;Pediatric

Core

3.0

7/17/2013

COMPLETE

International Standards for Neurological Classification of SCI Worksheet

The International SCI Data Sets

The International SCI Data Sets

SCI Classification S4-S5 sensory function result

Single Pre-Defined Value Selected

C06330

SCI Classification sensory zone of partial preservation left result

SCIClssSensZnePrtlPresrvLftRes

Result of the caudal extent of partially innervated segments, demonstrating partial preservation of sensory function on the left side of the body.